The MACRA Quality Payment Program (QPP) replaces the Sustainable Growth Rate (SGR) for setting the physician fee schedule rate changes and consolidates several quality and incentive programs into one. There are two performance tracks in the program, the Merit-Based Incentive Program (MIPS) and Advanced Alternative Payment Models (APMs). The Advanced APM track offers more predictable incentive payments through 2024 and a higher fee schedule increase from 2026 onward, but participation is limited for the 2019 payment period to those participating in select Medicare APMs in 2017 (see the list of included APMs at https://qpp.cms.gov/learn/apms). Eligible clinicians (ECs) who do not meet the Advanced APM participation requirements default to the MIPS track. According to the final rule for the MACRA QPP, in 2017, CMS estimates 70,000-120,000 ECs will be Qualified Participants in advanced APMs (vs. 600,000 in MIPS). This number increases to between 125,000 and 250,000 in 2018, and is expected to rise each performance year.
The MIPS program consolidates the Physician Quality Reporting System (PQRS), the Value-Based Modifier (VBM), and the EHR incentive program (meaningful use, MU) into one program with four performance categories: quality, cost, improvement activities, and advancing care information (ACI). The quality and cost categories are based on PQRS and VBM. The ACI category replaces MU, changing the “all or nothing” scoring method to a performance-based score that allows providers to opt-out of some measures not relevant to them. The improvement activities category is new, and providers must choose from a list of 92 activities (available at https://qpp.cms.gov/measures/ia).
2017 is the first reporting period for MIPS and will establish 2019 payment rates. To ease the transition to this new program, CMS will waive penalties to providers who report a minimum of one quality measure, one improvement activity, or a specified set of five ACI measures. MIPS ECs who report at least 90 consecutive days of performance data for all three categories will be eligible for a positive payment adjustment based on their relative performance against all submitting clinicians.
EHR-Related Issues to Consider
Since CMS leveraged existing programs to construct the MIPS performance criteria, clinicians will not have to adopt any new technology requirements in 2017, so long as they were previously compliant with PQRS and MU. Below are three specific factors to consider around EHR usage for the purposes of the MIPS program.
CMS offers bonus points in some categories to incent the use of EHRs. Clinicians will receive one bonus point in the quality category for end-to-end electronic submission of quality measures using certified electronic health record technology (CEHRT) to submit measures to registries or to CMS. Additionally, clinicians who use CEHRT to accomplish designated improvement activities will receive a 10% bonus in the ACI category. Those interested in maximizing their MIPS composite score in 2017 should take advantage of these opportunities.
CMS lists EHRs as an option for reporting on all three MIPS performance categories requiring data submission (no data needs to be submitted for the cost category in 2017). Keep in mind that the improvement activities category is new, as is group reporting for ACI, and CMS has not yet provided vendors with development specifications. Therefore, if you are interested in using the EHR as your reporting mechanism, check with your vendor about their plans to support data submission in 2017. Other reporting considerations include:
- Vendors may not support all of the electronic clinical quality measures (eCQMS), so validate which ones you are able to select and submit, if you are pursuing e-measures.
- Improvement Activities only require a yes/no attestation, but documentation likely will need to be provided if you are audited by CMS to show proof of attestation. ECs should analyze the list of activities to see which ones they or their organization are currently performing, and develop a plan of action to demonstrate and document how each activity is being performed. Not all activities can be tracked in the EHR directly without system modification or workflow changes.
CEHRT Upgrade Planning
In 2017, ECs can be on either 2014 Edition or 2015 Edition CEHRT. In 2018, 2015 Edition CEHRT is required for the MIPS reporting period.
- Consider upgrading during 2017, when the reporting period is flexible and reporting options are more lenient.
- Complete your upgrade and be ready for data collection to meet the 90 consecutive-day reporting requirement in 2018. Note: If you are participating in a CMS program with its own CEHRT requirements, such as CPC+, the reporting period requirements for those programs may not align with MIPS reporting requirements. For example, CPC+ participants must be using 2015 Edition CEHRT on 1/1/18 as the program requires a full year of use.
In conclusion, remember these three things when devising your MIPS strategy in 2017:
- Start 2015 Edition CEHRT upgrade planning discussions early with your EHR vendor to prepare for 2018.
- When selecting measures for the ACI or quality categories, emphasize your strengths and leverage familiar ground to maximize your MIPS Composite Performance Score.
- Overall, consider 2017 as a transition year to adapt to MIPS and plan for long- term change and success in the program.